Clinical Fraud Investigator II

Clinical Fraud Investigator II Location: Office 1‑2 days per week with flexibility for remote work. Alternate locations may be considered for candidates within commuting distance. Hybrid policy applies; candidates outside commuting distance are not eligible unless a legally required accommodation is granted. This position is not eligible for visa sponsorship. Responsibilities Perform comprehensive analysis and clinical evaluation of collected data. Perform in‑depth investigations on identified providers as warranted. Examine claims for compliance with billing and processing guidelines to identify fraud and abuse prevention opportunities. Review and conduct retrospective analysis of claims and medical records prior to payment. Research new healthcare‑related questions to aid investigations. Collaborate with the Special Investigation Unit and other internal areas on mutual concerns. Recommend possible interventions for loss control and risk avoidance based on investigation outcomes. Minimum Requirements Associate Degree in Nursing and/or current certification as a Certified Professional Coder (AAPC or AHIMA). Minimum of 4 years related experience, including at least 1 year in a Clinical Fraud and Abuse Investigation area (or equivalent education/experience combination). Preferred Skills, Experiences & Competencies Advanced Excel skills, including Pivot Tables. Legal and Accommodation Information Applicants who require accommodation to participate in the application process should submit the Accessibility Accommodation Request Form. Qualified applicants with arrest or conviction records will be considered for employment in accordance with applicable federal, state, and local laws. Equal Employment Opportunity Statement Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender, gender identity and expression, marital status, national origin, race, religion, sex, sexual orientation, veteran status, or any other status protected by applicable federal, state, or local laws. #J-18808-Ljbffr